National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 967830

History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 967830
VAERS Form:2
Age:64.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / UNK UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, Hypoxia, Pulse absent, Pupillary reflex impaired, Respiratory acidosis, Respiratory failure, Resuscitation, Unresponsive to stimuli, Pulseless electrical activity, Breath sounds absent, Bilevel positive airway pressure, Mechanical ventilation, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AMLODIPINE BENZOATE , ATORVASTATIN CALCIUM, ?LOSARTAN POTASSIUM, METOPROLOL SUCCINATE, metFORMIN
Current Illness: HTN, DM2. COVID-19 infection, 12/24/20.
Preexisting Conditions: HTN, DM2.
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was was brought to the ED from facility which he received the vaccine via ambulance with BiPAP, hypoxia, and one dose of Epi of 0.3 mg. He then required intubation, and had struggled with hypoxia, even on increasing PEEP. CODE BLUE called in the ED for PEA. He was medicated for such (please see the code run sheet for details), and he came in and out of the code 5 times. After 95 minutes, with the wife at the bedside, and family conference by phone, the code was called, and he was pronounced at 18:20. He received in total 8 me of Epi, 3 shots of Atropine, 3 amps bicarb. He got lasix 40 mg, lovenox 60 mg subcutaneous once. He had a CVC into the right internal jugular, and levophed was started, then Epinephrine drip was started. Prior to the code he got steroids (solumedrol 125 mg, then later decadron 6 mg iv), benadryl iv, antibiotics (ceftraixone / zithromax), and lasix 40 mg. All this time while in the ED, the Rt was at the bedside, and lots of secretions from the lungs were aspirated, bloody color. ? Code was the result of PEA secondary to hypoxia (


Changed on 5/7/2021

VAERS ID: 967830 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / UNK UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, Hypoxia, Pulse absent, Pupillary reflex impaired, Respiratory acidosis, Respiratory failure, Resuscitation, Unresponsive to stimuli, Pulseless electrical activity, Breath sounds absent, Bilevel positive airway pressure, Mechanical ventilation, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AMLODIPINE BENZOATE , ATORVASTATIN CALCIUM, ?LOSARTAN  LOSARTAN POTASSIUM, METOPROLOL SUCCINATE, metFORMIN
Current Illness: HTN, DM2. COVID-19 infection, 12/24/20.
Preexisting Conditions: HTN, DM2.
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was was brought to the ED from facility which he received the vaccine via ambulance with BiPAP, hypoxia, and one dose of Epi of 0.3 mg. He then required intubation, and had struggled with hypoxia, even on increasing PEEP. CODE BLUE called in the ED for PEA. He was medicated for such (please see the code run sheet for details), and he came in and out of the code 5 times. After 95 minutes, with the wife at the bedside, and family conference by phone, the code was called, and he was pronounced at 18:20. He received in total 8 me of Epi, 3 shots of Atropine, 3 amps bicarb. He got lasix 40 mg, lovenox 60 mg subcutaneous once. He had a CVC into the right internal jugular, and levophed was started, then Epinephrine drip was started. Prior to the code he got steroids (solumedrol 125 mg, then later decadron 6 mg iv), benadryl iv, antibiotics (ceftraixone / zithromax), and lasix 40 mg. All this time while in the ED, the Rt was at the bedside, and lots of secretions from the lungs were aspirated, bloody color. ?   Code was the result of PEA secondary to hypoxia (?   After 95 minutes of active resuscitation, the patient was found not responsive to painful stimuli. There was no palpable pulse. No spontaneous respirations. No heart or breath sounds by auscultation. Absence of pupillary light reflex.


Changed on 5/14/2021

VAERS ID: 967830 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / UNK UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, Hypoxia, Pulse absent, Pupillary reflex impaired, Respiratory acidosis, Respiratory failure, Resuscitation, Unresponsive to stimuli, Pulseless electrical activity, Breath sounds absent, Bilevel positive airway pressure, Mechanical ventilation, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AMLODIPINE BENZOATE , ATORVASTATIN CALCIUM,  LOSARTAN ?LOSARTAN POTASSIUM, METOPROLOL SUCCINATE, metFORMIN
Current Illness: HTN, DM2. COVID-19 infection, 12/24/20.
Preexisting Conditions: HTN, DM2.
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was was brought to the ED from facility which he received the vaccine via ambulance with BiPAP, hypoxia, and one dose of Epi of 0.3 mg. He then required intubation, and had struggled with hypoxia, even on increasing PEEP. CODE BLUE called in the ED for PEA. He was medicated for such (please see the code run sheet for details), and he came in and out of the code 5 times. After 95 minutes, with the wife at the bedside, and family conference by phone, the code was called, and he was pronounced at 18:20. He received in total 8 me of Epi, 3 shots of Atropine, 3 amps bicarb. He got lasix 40 mg, lovenox 60 mg subcutaneous once. He had a CVC into the right internal jugular, and levophed was started, then Epinephrine drip was started. Prior to the code he got steroids (solumedrol 125 mg, then later decadron 6 mg iv), benadryl iv, antibiotics (ceftraixone / zithromax), and lasix 40 mg. All this time while in the ED, the Rt was at the bedside, and lots of secretions from the lungs were aspirated, bloody color.   ? Code was the result of PEA secondary to hypoxia (  ? After 95 minutes of active resuscitation, the patient was found not responsive to painful stimuli. There was no palpable pulse. No spontaneous respirations. No heart or breath sounds by auscultation. Absence of pupillary light reflex.


Changed on 7/30/2021

VAERS ID: 967830 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / UNK UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, Hypoxia, Pulse absent, Pupillary reflex impaired, Respiratory acidosis, Respiratory failure, Resuscitation, Unresponsive to stimuli, Pulseless electrical activity, Breath sounds absent, Bilevel positive airway pressure, Mechanical ventilation, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AMLODIPINE BENZOATE , ATORVASTATIN CALCIUM, ?LOSARTAN LOSARTAN POTASSIUM, METOPROLOL SUCCINATE, metFORMIN
Current Illness: HTN, DM2. COVID-19 infection, 12/24/20.
Preexisting Conditions: HTN, DM2.
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was was brought to the ED from facility which he received the vaccine via ambulance with BiPAP, hypoxia, and one dose of Epi of 0.3 mg. He then required intubation, and had struggled with hypoxia, even on increasing PEEP. CODE BLUE called in the ED for PEA. He was medicated for such (please see the code run sheet for details), and he came in and out of the code 5 times. After 95 minutes, with the wife at the bedside, and family conference by phone, the code was called, and he was pronounced at 18:20. He received in total 8 me of Epi, 3 shots of Atropine, 3 amps bicarb. He got lasix 40 mg, lovenox 60 mg subcutaneous once. He had a CVC into the right internal jugular, and levophed was started, then Epinephrine drip was started. Prior to the code he got steroids (solumedrol 125 mg, then later decadron 6 mg iv), benadryl iv, antibiotics (ceftraixone / zithromax), and lasix 40 mg. All this time while in the ED, the Rt was at the bedside, and lots of secretions from the lungs were aspirated, bloody color. ? Code was the result of PEA secondary to hypoxia (? After 95 minutes of active resuscitation, the patient was found not responsive to painful stimuli. There was no palpable pulse. No spontaneous respirations. No heart or breath sounds by auscultation. Absence of pupillary light reflex.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=967830&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166